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Legal/Ethical Considerations for Accommodating Students with Mental Health Diagnoses CAPCSD 2016: San Antonio, TX 1 Disclosures Financial Florida State University: Employee CAPCSD: Complimentary conference registration Non-financial Council of Academic Programs in Communication Sciences and Disorders (CAPCSD): President-Elect Personal bias: Mood disorders are prevalent in my family 2 Mental Health on Campus (From NAMI, 2014) At least 80% of college students report feeling overwhelmed, with at least 45% of those reporting they felt their situation was hopeless “Mental Illness” describes a broad range of mental and emotional conditions Symptoms can be temporary or long-lasting, vary in consistency/person/episode 3 75% of lifetime mental health cases begin by age 24 Incidence is estimated to be 25% for adults between 18 & 24 More than 25% of college students have sought professional help for a mental health condition in the past year Most frequent diagnosis is anxiety, with depression occurring as the next most frequent 4 73% of students with a mental health condition reported experiencing a health crisis on campus, but 34% said that no one at their college knew 40% of students with a diagnosable condition do not seek help, more than half do not request accommodations (NAMI, 2012) 5 College mental health counseling centers & offices of disability services are experiencing ballooning caseloads Academic systems tend to rely on students to self-advocate Implies that students are willing to disclose Accommodations offered do not always correspond to needs of the student (McGuire, Madaus, Litt, & Ramirez,1996) 6 Academic & Clinical Implications Of Mental Illness Untreated severe depression can diminish prolonged cognitive functioning Anxiety may make information retrieval difficult Post-traumatic stress disorder may make it difficult to concentrate Malnourishment can lead to decreased cognitive functioning Reduced affect from the illness or its treatment can interfere in clinical interactions Difficulty in mood regulation may lead to inconsistent academic and clinical performance (Beckels & Wheeler, 2001) 7 CASE STUDY #1 8 Diagnoses & Symptomatology 9 Common Diagnoses Anxiety disorders Generalized Anxiety Disorder = 3.7% Obsessive-compulsive disorder = 1.9% Panic disorder = 0.6% Phobias Post-traumatic stress disorder Mood disorders Dysthymia = 4.9% Depression = 4.0% Bipolar disorder = 2% Eating disorders Anorexia = 0.2% Bulimia = 2.5% Other Schizophrenia Borderline personality disorder 10 General Signs & Symptoms of Mental Illness Marked personality change over time Confused thinking, strange or grandiose ideas Prolonged severe feelings of depression or anxiety Feelings of extreme highs/lows Heightened anxieties, fears, anger or suspicion; blaming others 11 Social withdrawal, diminished friendliness, increased self-centeredness Denial of obvious problems and a strong resistance to offers of help Dramatic, persistent changes in eating/sleeping habits Substance abuse Thinking or talking about suicide (from Center for Psychiatric Rehabilitation) 12 Signs & Symptoms In Class/Practicum Managing symptoms/tolerating stress Fatigue Negative side effects of medications Understanding areas of sensitivity as presented by the disability Making excuses for missed deadlines/poor quality work 13 Being able to devote equal effort to classes and clinic Being able to adjust to changes in demands presented by different environments Recognizing when stress is increasing and the associated implications Willingly asking for help/adjustments when needed Disclosing the disability 14 Solving problems/organizing work Recognizing a problem exists Identifying alternative solutions Being flexible with solutions Prioritizing tasks Meeting deadlines Following Code of Ethics, organizational procedures 15 Assessing own performance Recognizing areas in need of improvement Knowing when to ask for help Setting an agenda for supervisory/academic meetings Interpreting others’ cues Maintaining stamina/pace Quickly transition from client to client, or clinic to classroom Having energy to spend whole day on campus/in clinic Combating drowsiness from medications 16 Following schedule/attendance Handling time pressures and multiple tasks Being on time Consistent attendance Interacting with others Getting along/fitting in Interpreting social cues and work culture Being professional and accountable Responding to feedback Understanding/interpreting feedback or grades Knowing what to improve or how to initiate changes 17 Responding to change Coping with unexpected changes In client needs, assignments, due dates, or instructors Initiating new activities Sustaining concentration Screening out environmental stimuli: sounds, sights, odors Restlessness Shortened attention span Easily distracted Remembering verbal directions 18 Learning essential skills Divided attention tasks, e.g., providing stimulus & charting responses Responding to client verbal/nonverbal behaviors Providing feedback appropriately 19 What Can We Do? “The genius of good communication is to be at the same time as honest and kind as possible.” (Center for Psychiatric Rehabilitation) 20 Disability Law & Mental Health Section 504 of the Rehabilitation Act of 1973 “No otherwise qualified person due to disability may be denied participation in, denied the benefits of, or subjected to discrimination (29 U.S.C. § 794 (a)) Americans with Disabilities Act of 1990 Title II: Prohibits public entities from denying qualified persons with disabilities right to participate in, benefit from services/programs/activities (42 U.S.C. § 12132) 21 Otherwise qualified Person must be able to meet the essential eligibility requirements of the program An individual is qualified for the program if he/she can meet admission, academic & technical standards Administrators may take into account the functional limitations arising from the disability, provided limitations are relevant to the reasonable qualifications Duty to Investigate The program must assess each student’s ability to succeed given new learning strategies and adjustments Assessment can’t be based on stereotypes Courts have deferred to faculty judgment 22 Fundamental Alteration Occurs when requirements of the program of study are substantially altered or reduced Requirements must be reasonable & essential to the program If the program believes a requested accommodation is a fundamental alteration Alternative adjustments should be explored Reasons the accommodation would be a fundamental alteration should be documented Programs are not obligated to provide the accommodation in cases of fundamental alteration Reasonable accommodation Adjustments should match the individual need of the student Student should be able to meet core requirements without the adjustment Adjustments should not affect grading standards 23 CASE STUDY #2 24 Why Is It So Hard To Know What To Do? We try to make decisions that end up being led by our morals vs. our Code of Ethics Common Ethical/Moral Conflicts When It Comes to SMI Holding welfare of someone else paramount Whose welfare? Client’s or student’s? Competence in practice Scope of practice Dual relationships Having both a professional and personal relationship with someone Ethical Values Autonomy Commitment to respect an individual’s independent actions & choices Beneficence Obligation to convey benefits and help others further their legitimate interests Harm avoidance (nonmaleficence) Obligation not to inflict harm, risk of harm or evil on others Justice Equal distribution of burdens, benefits, and scarce resources Professional responsibility Obligation to observe rules of professional conduct with patients, colleagues, students, community at large Truth Disclosure of all pertinent information, even if it may reflect poorly on the informer 28 Morals Definitions based on the individual Moral judgments are typically subjective rather than obvious or consistent across societies or belief organizations. Often decided intuitively because of deep emotional convictions. Moral judgments are value judgments that are made in real time situations (Broidy) Differences between Ethics and Morals Definitions often overlap Based on emotions Can be subjective Provide guidance/structure to interactions Occur in real-time Many theorists use terms interchangeably Both are emotionally-laden constructs ASHA Code of Ethics Definitions Diminished decision-making ability: Any condition that renders a person unable to form the specific intent necessary to determine a reasonable course of action. Impaired practitioner: An individual whose professional practice is adversely affected by addiction, substance abuse, or health-related and/or mental health–related conditions. 31 Principle I, Rule R: Individuals whose professional practice is adversely affected by substance abuse, addiction, or other health-related conditions are impaired practitioners and shall seek professional assistance and, where appropriate, withdraw from the affected areas of practice. Principle I, Rule S: Individuals who have knowledge that a colleague is unable to provide professional services with reasonable skill and safety shall report this information to the appropriate authority, internally if a mechanism exists and, otherwise, externally. Principle I, Rule T: Individuals shall provide reasonable notice and information about alternatives for obtaining care in the event that they can no longer provide professional services. Principle IV, Rule D: Individuals shall not engage in any form of conduct that adversely reflects on the professions or on the individual's fitness to serve persons professionally. 32 Principle IV, Rule I: Individuals shall not knowingly allow anyone under their supervision to engage in any practice that violates the Code of Ethics. Principle IV, Rule L: Individuals shall not discriminate in their relationships with colleagues, assistants, students, support personnel, and members of other professions and disciplines on the basis of race, ethnicity, sex, gender identity/gender expression, sexual orientation, age, religion, national origin, disability, culture, language, dialect, or socioeconomic status. Principle IV, Rule N: Individuals shall report members of other professions who they know have violated standards of care to the appropriate professional licensing authority or board, other professional regulatory body, or professional association when such violation compromises the welfare of persons served and/or research participants. 33 AAA Code of Ethics Principle 2, Rule 2f: Individuals shall maintain professional competence, including participation in continuing education. Principle 6, Rule 6a: Individuals shall not misrepresent their educational degrees, training, credentials, or competence. Only degrees earned from regionally accredited institutions in which training was obtained in audiology, or a directly related discipline, may be used in public statements concerning professional services. 34 What Programs Can Do: Before Students Are On Site Clearly state in admissions information and program policy documents (e.g. program handbooks for students)… Information about disability services on campus and how to become identified Information about mental health services The options that exist for students who are unable to meet program standards Due process within the organization Non-clinical track Dismissal can occur Expectations for performance and program policies that might lead to a student’s dismissal 35 Examples of Policy Language “Demonstrate the emotional health necessary to apply knowledge effectively and to exercise appropriate judgment.” Must be “flexible and creative in order to adapt to professional and technical change and function in new and stressful environments.” “The faculty/clinical staff reserve the right to request the withdrawal of any student whose conduct, health, or performance demonstrates lack of fitness for continuance.” “Demonstrate interpersonal skills appropriate for the profession.” Based on the professional judgment of faculty through regular reviews of student progress. “Students must possess the emotional stability to enable them to develop therapeutic relationships and successfully communicate with individuals….” “Students should be emotionally able to handle demanding workloads and to function effectively under stress.” In a definition of “unprofessional conduct”, list “mental or physical incompetence.” 36 Before students enter cont. … Faculty should develop awareness of campus resources such as mental health and disability services The program should have written documentation of functional skills needed for successful program completion Consider what reasonable accommodations might be for these skills Implement a student review mechanism for ALL students 37 What Programs Can Do: Once Students Are Attending/On Site Understand potential implications of accommodating students informally Slightly different than “academic freedom” Confusing to the student May create an environment where the student learns to manipulate the system May create a potential legal problem down the road 38 Privacy The student does not have to disclose specifics about the disability to the instructor/supervisor/department The program CANNOT disclose information to Off-site supervisors unless The affiliation agreement specifies that the student is there for an academic (clinical) experience – be very careful about this The student authorizes release of information Other school officials (e.g., even department colleagues) unless there is a “legitimate educational interest” Parents if the student is > 18 unless the student is a dependent for income tax purposes 39 CAN disclose information To law enforcement agencies In connection with an emergency 40 Possible Accommodations for SMI In the classroom Use preferential seating Assign accompanier/classmate/volunteer assistant Permit beverages Schedule pre-arranged breaks Increase frequency of grading opportunities Allow delay for assignment due dates Use flexibility in determining full-time status Allow “stop-out” vs. “drop-out” Assign incompletes vs. “F” or “W” (Center for Psychiatric Rehabilitation) 41 When considering accommodations for clinical settings… What is expected of all students at this stage of clinical development? Is the student “otherwise qualified?” What are the essential/nonessential functions of the practicum assignment? How will you evaluate the functional limitations of the student in this assignment? 42 In clinical settings Assign a co-clinician Permit beverages Allow pre-arranged breaks Adjust clinic/internship schedule Change supervision model 43 If You Have GENERAL Concerns About A Student Be open and honest State that you are concerned Make specific observations I’ve noticed that … In the past, other students I’ve known who … I’m wondering whether this might be true for you? Ask questions Are you eating Are you sleeping Does anyone else know you’re feeling a bit stressed right now? Has this ever happened before? 44 Offer some options Talking with advisor Contacting on-campus resources University counseling center University health center Psychology department? Crisis lines Suggesting the student talk to his/her physician or religious advisor Document that your observations, the interaction, and any steps discussed/taken 45 If You Have Concerns About An ACUTE Situation Recognize signs of decompensation Extreme emotion Physical symptoms – shaking, sweating, changes in respiration, noticeable lack of cleanliness/neatness Cognitive symptoms -- Not processing/distracted, inappropriate responses in conversation or in writing Other symptoms: Unusual behavior or speech that you’ve not observed before Be open and honest I am very concerned I need you to be very honest with me right now 46 Make specific observations I’m noticing that … Ask questions Can you tell me what’s going on? Are you sleeping? How much/how often? Are you eating? Are you taking anything? Are you seeing a doctor? Does anyone else know you’re struggling right now? Have you had any thoughts about hurting yourself? 47 Take action I am not comfortable with you leaving my office until I know you are going to be cared for by somebody Would you like me to call or would you like to make the call from my phone? State to the service provider that it is an emergency and the student needs to be seen immediately Counseling center, health center, student’s physician, university police Is there anyone else we need to call (e.g., parents) 48 Document your observations, the interaction, and the steps taken 49 CASE STUDY #3 50 When Is Dismissal Appropriate? When a student fails to meet grade or other academic requirements Cannot require that a student attend therapy or take medication as a disciplinary measure Can determine that “fund of knowledge” is insufficient Faculty has right to use “professional, academic judgment that a student cannot meet the school’s academic requirements” Clinical experiences are considered academic requirements 51 To dismiss a SMI In general, wrongdoing/insufficient performance must be carefully documented All students must be subjected to same policies and procedures Appropriate due process must be provided 52 Dismissal Is Appropriate When… The student is failing in spite of accommodations Is there a flow from probation to dismissal? Are there clear criteria for dismissal? Has due process been followed? Documentation of functional limitations and accommodations attempted Honest discussions with student Advance warning Have alternate steps been explored? Changes in accommodations? 53 Dismissal Can be dismissed for disciplinary reasons when there are violations of Criminal laws University code of conduct Program code of conduct Office of Civil Rights emphasizes that prior to dismissing a SMI for failure to meet essential function standards, the university must provide the student Reasonable notice of the standards The basis for the belief that the student is not meeting the standards A reasonable opportunity to modify the behavior or engage in counseling 54